ACMT COVID-19 Web Series FAQs

A number of proposals allow for triage based on acuity of disease manifestations (e.g., symptoms, vital sign abnormalities) and risk factors for poor outcome (e.g., obesity, diabetes, hypertension). Various strategies have been suggested – please see the World Health Organization’s interim guidance for clinical management of severe respiratory infection when COVID-19 is suspected and discussion from the Centre for Evidence-Based Medicine at the University of Oxford regarding use of modifications of the National Early Warning Scale (NEWS and NEWS2) for grading clinical severity.

Minimally symptomatic patients can be sent home with follow-up after a medical screening exam if their oxygen saturation is “reasonable” (e.g,, O2 sat >93% at rest). Encouragement to sleep prone and telephone-based follow-up are reasonable considerations at this time.

Patients – whether discharged or admitted – have a number of other concerns beyond their own health. The safety of interacting with friends and family is still a concern since we do not yet fully understand the risk of recurrence of COVID, either intrinsically or from re-exposure, as well as the risk of contagion related to the carrier state status. Encouragement of hand hygiene, cleaning of surfaces, use of face coverings, and continued isolating from higher-risk individuals are still recommended as action steps that patients can take. Our current limited understanding of the long-term outcomes of recovered patients with COVID leaves patients anxious with anticipation about delayed complications. Economic uncertainties weigh heavily on many given the broad implications – both immediate and for the future - encompassing daily needs, health insurance, availability and safety of medical care, and retirement. Specialty societies, local institutions, and many community-based organizations are responding to these needs. Some of these resources are compiled by the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC), but local resources, if available, are likely to be more effective at addressing patients’ specific needs.

REFERENCES:

Coronavirus (COVID-19). CDC. Last accessed April 27, 2020 at: https://www.coronavirus.gov/

Greenhalgh T, Treadwell J, Burrow R, et al on behalf of the Oxford COVID-19 Evidence Service Team. NEWS (or NEWS2) score when assessing possible COVID-19 patients in primary care? The Centre for Evidence-Based Medicine, University of Oxford. April 8, 2020. Accessed at: https://www.cebm.net/covid-19/should-we-use-the-news-or-news2-score-when-assessing-patients-with-possible-covid-19-in-primary-care/

National Institute of Mental Health. Help for mental illnesses. NIH. Last accessed April 27, 2020 at https://www.nimh.nih.gov/health/find-help/index.shtml

World Health Organization. Clinical management of sevre acute respiratory infection when COVID-19 is suspected: interim guidance. 13March2020. Accessed at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected

There has been a decrease in the number of presentations to EDs of patients with both psychiatric and substance misuse related complaints over the last months (as well as that of most non-respiratory complaints). However, this does not mean that these problems have decreased. Multiple factors, including but not limited to, illicit supply chain disruption (impacting availability of fentanyl analogs), use in safer venues due to quarantine, increased availability of buprenorphine due to reduced prescribing restrictions, reduced EMS transport availability, fear of calling EMS to bring overdosed friends/family to the ED, innovative outpatient treatment modalities, may play a role. Note that some of these may decrease risk of overdose or decompensation, while others will increase it, resulting in contrary impacts on reported attributable morbidity and mortality.  

More information:

Addiction Medicine Case Conferences

Telehealth lends itself well to substance misuse management (more info here), but face-to-face encounters are very important for establishing rapport, maintaining contact and reinforcing positive behaviors. Resumption of face-to-face encounters will likely follow the pattern of reinstitution of all healthcare and economic activity. Continued use of risk reduction steps will likely continue for months. These include:

1. good ventilation of outpatient care areas and patient consultation rooms;
2. wearing of face coverings by patients and providers;
3. good hand hygiene practices;
4. limiting exposure with use of N-95 respirators for practitioners conducting higher risk practices such “mouth checks” following oral medication.